Broken Electrical Outlet Faceplate at Nurse Station
Summary
A deficiency was identified when an electrical outlet at Nurse Station #2 was observed to have half of its faceplate cover broken, exposing metal terminals. This observation was made during a walkthrough with the Chief Medical Officer (CMO), who stated he had not previously noticed the broken faceplate. The facility's policy and procedure for the Preventative Maintenance Program, dated 12/19/2022, assigns responsibility to the Maintenance Director for ensuring that buildings and equipment are maintained in a safe and operable manner. The exposed outlet was not protected as required by NFPA 70, 2011 Edition, Article 406.6, and this lapse was found to affect one of five smoke compartments in the facility.
Plan Of Correction
K511 Utilities - Gas and Electric CFR(s) NFPA 101 Corrective Action Initiated for those resident(s) found to have been affected by deficient practice Upon notification of the deficient practice on 05/28/2025, the MS changed the faceplate of the electrical outlet at Nurse Station #2 on 05/28/2025. (Exhibit #3) How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. There was no other trend identified and no other residents were affected by this deficient practice. Measures put into place or systematic changes the facility will make to ensure the deficient practice does not occur On 05/28/2025, the ADM provided an in-service/re-education to MS regarding policies and procedures on Preventative Maintenance Program, ensuring all electrical receptacles were maintained free of damage. Monitoring for the effectiveness and the sustainability of the corrective action put into place to correct the issue identified. An observational audit of the electrical receptacles will be done once a month by MS for 3 months. A summary of this deficient practice will be brought to the monthly QA meeting for 3 months by MS for evaluation of the plan effectiveness and sustainability.
Penalty
Surveyors identified that the facility’s electrical system was not maintained according to NFPA 101 and NFPA 70. In the kitchen electrical panel, breakers labeled for the dishwasher were in the off position while the dishwasher continued to run with power. In generator sub panel B, a breaker was labeled for a sprinkler pump even though no sprinkler pump existed, and there was an open breaker position without a blank cover. These issues were confirmed by the Maintenance Director and had the potential to affect all residents.
Improperly Labeled and Maintained Electrical Panels
Penalty
Summary
Surveyors found that the facility failed to maintain its electrical system in accordance with NFPA 101-2012 and NFPA 70-2011, potentially affecting all 69 residents. During a tour of the facility, surveyors observed in the kitchen electrical panel that the breakers labeled for the facility’s dishwasher were in the off position while the dishwasher itself was running and had power. Later, in generator sub panel B, surveyors noted a breaker labeled as a sprinkler pump even though the facility did not have a sprinkler pump, as well as an open breaker space without a blank installed. The Maintenance Director confirmed these findings at the time they were discovered. No specific residents, medical histories, or clinical conditions were mentioned in relation to these deficiencies.
Plan Of Correction
1.Based on observation and staff interview, no residents experienced negative outcomes related to electrical system deficiencies. The facility's kitchen dishwasher breakers were in the off position; the dishwasher was running and had power. It was also noted that in generator sub panel B there was a breaker listed as sprinkler pump as well as an open breaker that has no blank, while the facility has no sprinkler pump. 2.The Medical Director was notified by LNHA on 03/26/2026 of deficiencies including improper breaker configuration and labeling. 3.Electrical deficiencies will be corrected by licensed electrician on or before 04/30/2026. 4.Monthly inspections will be conducted and compliance reviewed in QAPI. 5.LNHA educated 03/26/2026 regarding the requirements for maintaining the facility's electrical equipment, including the requirements for the facility's kitchen dishwasher breakers' requirements in power being active and breaker reflecting that it is on, and vice versa. Also, Maintenance Direct was educated in the importance of ensuring the appropriate labeling of breakers.
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